Breast Fibrocystic Disease

Breast Fibrocystic disease, also termed “Fibrocystic changes” (FCC) is the general, all-inclusive term for a whole range of common and benign breast disorders.

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These include various types of cysts (which contain fluids), and ‘solid lesions’ such as adenosis, epithelial hyperplasia, radial scar, apocrine metaplasia, and papilloma.

Fibrocystic changes are extremely common, occuring in 90% of women at some point in their lives. However, most fibrocystic changes tend to occur with younger, premenopausal women. While no one knows exactly what genetic or biological factors would predispose a woman to fibrocystic breast disorders, it is generally accepted that hormonal imbalances, particularly with regard to levels of progesterone and estrogen, are the most likely cause.

How are FCC breast fibrocystic changes discovered?

Most fibrocystic breast disorders are either discovered clinically, or brought to the attention of a family physician because of breast symptoms a women notices herself. These might include soreness, redness, unusual discharges, or possibly a bulge or fibrocystic breast lumps. For women who begin breast cancer screening at an earlier age (40s.. which is recommended ), some of these fibrocystic changes may be discovered as a curious finding on a screening mammogram. Usually there is enough information on the mammogram itself to rule out malignant breast cancer, but follow up procedures such as ultrasound and biopsy may be utilized as well. A fibrocystic disorder may be described to a patient as a ‘lesion’, which is a term commonly used to described early breast cancer developments, but this should not set off alarm bells. A ‘lesion‘ simply means a “thing we are talking about.”

Are breast fibrocystic diseases related to breast cancer?

Fibrocystic changes to the breast are not related to breast cancer. However, some of the disorders can occur simultaneously with breast cancer development, which is why they are taken seriously and fully investigated, just to be sure. The most important issue in fibrocystic diseases, particularly the solid lesions, is whether or not the cellular changes which are occuring would be described as ‘typical’, or ‘atypical’. Where ‘atypical’ cellular growth and change is occuring, then yes, it may be related to breast cancer.

This has been a topic of interest in breast cancer research for many years. Generally speaking, the only increased risk associated with fibrocystic disease is the same slightly elevated risk for all women who show a genetic predisposition towards breast fibrocystic breast changes. (Approximately the same risk as having a relative who had breast cancer.)

However, it is possible that some breast disorders are secondary to changes in breast tissue resulting from carcinoma, occuring simultaneously. Bear in mind, however, that breast cancer tends to present in fairly predictable and distinguishable ways, and these factors would be apparent. Breast cancer also tends to occur with older, post-menopausal women.

Epithelial proliferations

Of the common breast fibrocystic disorders, the category which is perhaps most allied to the biology at least, of breast cancer, would be epithelial proliferation. Proliferation means ‘cells are growing’, and this is also something which breast cancer cells do. The question, again, is whether or not there is anything ‘atypical’ (random or grossly distorted) about either the appearance of the cells, or their formations. However, even with these ‘atypical’ fibrocystic proliferations the risk of subsequent breast cancer development is very low.

“Non-proliferative” versus “Proliferative” lesions.

The different types of breast fibrocystic changes are often categorized as ‘proliferative’ or ‘non-proliferative’. Non-proliferative fibrocystic disorders are those in which the problem has not been caused by new or unexpected cell growth. These are the more ‘nuts and bolts’, or ‘bread and butter’ types of breast problems that can occur from imbalances in secretions, blockages due to mineral deposits, infections, traumas – this sort of thing. Common non-proliferative lesions would include periductal fibrosis, nonsclerosing adenosis, duct ectasia, cysts, epithelial-related calcifications, mild epithelial hyperplasia and papillary apocrine changes. Non-proliferative lesions are the most common finding in breast cancer screening biopsies, accounting for about 70% of all cases.

Is there anything ‘atypical’ about a proliferative breast growth

Proliferative breast changes/lesions on the other hand do involve the growth of new cells, and that makes this category of fibrocystic disease a little more worrisome, at least initially, for the possibility of underlying breast cancer. The question again is whether or not the cell proliferations are ‘typical’ or ‘atypical’. Among the proliferative fibrocystic breast changes ‘without atypia’ are sclerosing adenosis, radial scar, intraductal papilloma, and moderate to florid hyperplasia (‘of the usual type’). A finding of ‘hyperplasia’, which means extensive new cell growth, is really the only one which would conceivably be related to breast cancer. It would depend on the nature of this hyperplasia; how much?, what do the cells look like?, what kinds of patterns and distributions do they exhibit?

The risk of breast cancer remains very low, even for atypical hyperplasia

So, ‘atypical’ proliferative fibrocystic changes would include ‘atypical ductal hyperplasia‘ and lobular hyperplasia, where atypical cell growth is occuring in the breast ducts or less commonly in the breast lobules. Atypical ductal hyperplasia (ADH) can be an early manifestation of breast cancer. However, it must be remembered that the absolute risk for developing breast cancer, even for atypical proliferative lesions is still very low. Over 80% of women who are diagnosed with atypical hyperplasia will never develop invasive breast cancer.

Cysts

Breast cysts are round or oval lesions which are fluid-filled. They are extremely common, occuring in up to 1/3 of women between in the mid-30s to 50 year old range. The type of fluid within the cysts and the amount of solid elements can be variable, which leads to sub-classifications of ‘simple cyst’, or ‘complicated cyst‘ and ‘complex cyst’.

Adenosis

Adenosis is a ‘proliferative’ breast disorder characterized by an increase in the number and size of glandular tissues, usually within the breast lobules. Different types of adenosis worth noting include a sclerosing adenosis ( hardening ) and microglandular adenosis (MGA). Other minor subtypes of breast adenosis include apocrine adenosis, adenomyoepithelial adenosis, and ‘blunt-duct’ adenosis.

Apocrine Metaplasia

Metaplasia is a particular kind of basically non-proliferative cell growth, which is characterized not by excessive growth of new cells, but rather a change or replacement of one type of cells with another. Typically, these new cells develop as a result of an irritation of some kind. Apocrine metaplasia is a unique breast fibrocystic lesion characterized by ‘columnar’ cells, and ‘apocrine’ protein patterns. This condition is most common in young women and is considered benign. It is possible, however, for apocrine metaplasia to present in an ‘atypical’ pattern, which would be more cause for concern.

Metaplasia

Another highly rare breast metaplasia is ‘clear cell metaplasia‘. It is named because certain morphological characteristics bare a similarity to clear cell breast carcinoma, although they are not related. (Metaplasia does not suggest carcinoma, unless there are significant atypical features)

Epithelial Hyperplasia

Epithelial hyperplasia refers to new cell growth occuring in lining tissues (epithelial cells) but in places other than the breast ducts or breast lobules. It that sense it is kind of a nondescript proliferative breast lesion. As is the case with ductal and lobular hyperplasia, epithelial hyperplasia may have ‘usual’ characteristics ( benign ) or ‘atypical’ characteristics, which are somewhat more suspicious of malignancy.

Ductal Hyperplasia

Ductal Hyperplasia means that a lot of new cell growth is occuring within breast duct elements. In the non-worrisome, benign form (typical), ductal hyperplasia has quite a uniform patterning of cells. Atypical ductal hyperplasia (ADH), however, is not necessarily benign and may be a low grade presentation of ductal breast carcinoma in situ. ( DCIS )

Lobular Hyperplasia: lobular neoplasia

Just like ductal and epithelial hyperlasia, lobular hyperplasia implies new and rapid cell growth in the area of the breast lobules. ‘Atypical lobular hyperplasia‘ indicates unusual cell features and patterning. If the cellular distortions are significant enough, the condition may be termed lobular carcinoma in situ (LCIS), although the only difference between atypical lobular hyperplasia (ALH) and LCIS is the degree and extent of epithelial proliferation. The common standard now is to collectively place atypical lobular hyperplasia under the banner of ‘lobular neoplasia‘. This is a very rare breast lesion, and is basically managed as a risk fact for breast cancer only. There is no consistent, direct link between lobular neoplasia and invasive breast cancer.

Flat Epithelial Atypia, or Columnar cell breast lesions

Flat epithelial atypia, also called a breast ‘columnar cell lesion’, is not a term in broadly accepted, common use. Essentially, these are new cells which have mysteriously replaced the ‘native’ cells in the areas surrounding microcalcifications discovered on a breast cancer mammogram. The pattern of growth is ‘flat’, visually, hence the name. This is an area of current research and not a lot is know about flat epithelial atypia. However, as certain patterns of microcalcifications have been associated with the development of ductal carcinoma in situ (DCIS), flat epithelial atypia cells may also be associated with early development of DCIS.

Radial Scar, Complex Sclerosing Lesion

A radial scar, so-named because of the radiating/star like appearance on a breast X-ray, is a proliferative pseudo-lesion caused cell hyperplasia in the breast ducts. The significance of a radial scar is uncertain, though they are believed to be an increased risk factor for breast cancer. Sometimes radial scars are accompanied by adenosis, epithelial hyperplasia, duct ectasia, and papillomatosis.

A ‘complex sclerosing lesion’ is essentially the same finding as a radial scar; just larger in size. The term ‘radial scar’ tends to be used for lesions less than 1 cm, while complex sclerosing lesion is used when they are larger than 1cm. Note, there is typically no ‘central mass’ to a radial scar and they will not be clearly detected on ultrasound. Usually a biopsy is required, as the appearance of a radial scar can mimic that of tubular carcinoma.

Papilloma and Papillomatosis

A papilloma is a benign proliferative tumor that grows within the epithelial lining of breast ducts. This growth tends to from ‘fronds’ or ‘finger-like’ projections, and can block or partially block the normal flow of breast secretions. The classic symptoms for papilloma would include nipple discharge, but also breast swelling and pain, and possibly a lump. But no one knows exactly what causes the growth of papilloma, as biopsy confirms that the cells do not contain malignant carcinoma. It is generally considered an increased risk factor for breast cancer, though there is no direct, proven link between its appearance to the development of invasive breast carcinoma.

Solitary or multiple papillomas

Normally they occur in isolation ( solitary papilloma ), but papillomas which develop towards the extreme ends of the ductal system can be multiple. The development of multiple breast papillomas is termed ‘papillomatosis’.

Breast Adenoma (Fibroadenoma)

An ‘Adenoma‘ is the name for a benign tumor ( ‘oma’ means tumor, or mass) which has developed primarily from ‘glandular’ epithelial cells. Because it is a proliferative ‘neoplasm’ ( an area of rapid new cell growth), and adenoma bears similarity to a malignant, cancerous tumor. However, generally adenomas will generally not metastasize and will remain benign. The problem with adenomas is that they can cause blockages and impairments to normal breast function, and they can also be a sign of hormonal imbalances.

Fibroadenoma

The most common breast adenoma is called a ‘fibroadenoma‘, which means that the fibrous and glandular cells supporting milk production have ‘overgrown’. A fibroadenoma will likely present clinically as a firm, painless, and mobile breast mass which can often be felt. Fibroadenomas are the single most commonly observed breast lesion, and tend to occur with younger, premenopausal women. There is some speculation that the risk of developing fibroadenoma may be linked to the use of birth control medications.

Lactating Adenoma

Other sub-types of breast adenoma include lactating adenoma, which is associated with pregnancy and lactation, and tubular adenoma ( which may also be called ‘pure adenoma’), which has much less growth of stromal elements and large ducts, and is more confined to the smaller acinii of the milk producing glands.

Fibroadenomas with complexity

About half of all fibroadenomas will contain other proliferative changes of the breast, such as duct hyperplasia, adenosis, and sclerosing adenosis. Where these mixed elements are present the lesion is sometimes called a ‘complex fibroadenoma’. In terms of the possibility of breast cancer, adenomas are not associated with any increase. However, women with complex fibroadenomas may have a slightly increased risk for breast cancer over the longer term.

Nipple Adenoma

A nipple adenoma is a benign growth of ductal epithelial cells either on or underneath the nipple. It is usually discovered either as a small lump a woman discovers herself, or because of nipple erosion or nipple discharges.

Hamartoma

A Hamartoma as an uncommon tumor-like mass which contains varying amounts of fibrous, glandular, and adipose (fat) tissue. Unlike adenomas, a hamartoma is not characterized as a ‘neoplasm’. The cells involved are all ‘native’ to the area and are growing at the same rate as surrounding tissues. It is more a kind of ‘disorganization’ (dysgenesis) rather than a result of some kind of malignant cell process, and is completely benign. No one is sure what brings on a hamartoma, but problems associated with hamartoma are potential duct blockages and unwanted cosmetic effects. They are typically surgically removed, but only after careful differential diagnosis for breast cancer.

Lipoma

A lipoma is essentially a lump caused by an accumulation of mature fat cells. It is a ‘benign neoplasm’ caused by some cells growing and dividing more rapidly than others. It is sometimes called a ‘soft tissue’ tumor because it develops among the soft, fatty tissues of the breast. It is harmless, generally painless, soft to the touch, and moveable. A lipoma tends to be a ‘common sense’ diagnosis based on clinical exam, mammogram, and ultrasound finding, and is generally just left alone and watched over time. Lipomas do not transform into breast cancer. Note, lipomas can occur anywhere on the body where there is fat tissue, and really have nothing to do with the breast specifically.

Diabetic Fibrous Mastopathy

Diabetic Fibrous Mastopathy is an uncommon breast lesion occuring mostly in premenopausal women, but also in some men with long-standing type 1 diabetes, especiallly those who are insulin-dependent or who have had microvascular complications. Sometimes diabetic fibrous mastopathy presents as a painless, immobile lump, or else is found on a breast cancer screening mammogram. It is characterized by overgrowth of connective tissues with vasculitis (inflammed or destroyed blood vessels) and some proliferation of ductal epithelium. These lesions can occur singly or in multiples and tend to be ‘ill-defined’ in terms of shape, and this can raise suspicions for breast carincoma. However, it is entirely benign and unrelated to breast cancer.

Granular Cell Tumor

Granular cell breast tumors are rare and usually benign neoplasms that may develop from ‘Schwann Cells” of the peripheral nervous system. It is more characteristic for these ‘soft tissue’ tumors to develop in the head and neck region, but about 5-6% of the time they develop within breast tissue. Granular cell tumors are usually discovered clinically prior to a screening mammogram. They are rock-hard to the touch and seem to be ‘fixed’ to the skin. Because of the firmness of the lump, ill-defined mammographic features, and even visual and textural aspects of excised biopsy samples, these tumors can mimic breast cancers, particularly apocrine carcinoma. However, microscopic features of granular cell breast tumors are quite regular, and benign. Granular cell breast tumors are not 100% benign, however. There are rare instances of malignant and metastasic granular cell tumors, but typically in these cases the cytological and microscopic features suggestive of malignancy are very obvious in the histological analysis. Glandular cell tumors tend to occur in women over 50, and it seems to be slightly more common in ethnic black individuals.

Pseudoangiomatous Stromal Hyperplasia of the Breast

Pseudoangiomatous stromal hyperplasia (PASH, and sometimes called Pseudoangiomatous hyperplasia of mammary stroma) is a rare and benign proliferation of mesenchymal cells (stem cells which frequently form into connective tissues). Sometimes PASH is just an incidental microscopic finding in biopsies performed for other reasons, but at other times it can develop into a large mass. It occurs almost exclusively in younger, premenopausal women, and features a large overgrowth (hyperplasia) of breast stromal cells and tissues. The cause of PASH is uncertain. It was originally thought to be related to hormone levels, but this relationship has not been consistently demontrated. PASH is completely benign, and the only concern in the ‘investigative’ stages is that aspects of its presentation can mimic carcinoma, particularly angiosarcoma.